Brinks Paycard Form – eEmployers Solutions, Inc.

Notice: Data entered into this form will be encrypted to ensure the safety of your data.

Name*
First Middle Last
Social Security Number*
Company Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Date of Birth*
MM slash DD slash YYYY
I am requesting a:*
- Full deposit
- Partial deposit
Partial deposit amount (if applicable)
Electronic Consent*
I have read and agree to the terms and conditions
By checking the electronic consent box above you: (1) acknowledge and agree that you have chosen the Brink’s Money Program and that
you were given an opportunity to review the Cardholder Agreement, Privacy Policy, and Fee Schedule in
advance; (2) authorize BofI Federal Bank to establish your Brink’s Money Account and issue your Brink’s
Money Card; (3) authorize your employer to: (a) transmit the information that you have provided to Skylight
and BofI Federal Bank, and (b) deposit your wages into your Brink’s Money Account, all subject to the
Cardholder Agreement and Fee Schedule.